JAKARTA, DENPASAR––The U.S. embassy to Indonesia on January 12, 2009 issued the outbreak notice that the Bali tourism industry had feared would be coming since mid-November 2008, when reports first circulated about four human rabies deaths resulting from dog bites in two villages on the peninsula south of the Denpasar airport.
“Rabies has been confirmed in dogs from at least two villages near popular tourist destinations on the southern tip of Bali,” the outbreak notice advised. “At this stage rabies has been identified in only one district, but the Centers for Disease Control & Prevention advises travelers to take precautions on the entire island,” the notice added.
The outbreak notice was distributed two days after Bali governor Made Mangku Pastika announced, “We are closing the seaports and airport to any dog trade.”
But the dog trade most likely to spread rabies throughout Bali continued unabated. Dani Stokeld of the Bali Animal Welfare Association shared photographs documenting how BAWA personnel followed a private dogcatcher as he captured as many as 10 street dogs from the area where rabid dogs have been found: of the first 50 dogs tested, nine were reportedly confirmed rabid. The dogcatcher then hauled the dogs in gunny sacks to a dog meat restaurant in Singaraja, on the far side of Bali, beyond the central mountains.
“They followed this guy all the way to a woman s house, who said she makes dog satay and sells it at her restaurant, where local police often eat,” said BAWA founder Janice Girardi. “They know there is no law against this, and were quite open about what they are doing. I mentioned it to the head of the Bali animal husbandry service and he didn’t even show concern. I offered him the license plate number of the dogcatcher’s motorcycle, and he just was not interested.”
That was scarcely Girardi’s only frustration with Bali animal husbandry chief Ida Bagus Ketut Alit. “He is following the Indonesian protocol book for dealing with rabies,” Girardi explained.
The book, when Girardi obtained copies of it from the national capital in Jakarta on January 5, turned out to be Dutch laws written in 1926, when Indonesia was a Dutch colony.
“They will continue to cull all unvaccinated dogs, and will only vaccinate owned dogs,” Girardi summarized. “They only have a total of 20,000 vaccine doses,” to serve a dog population officially estimated as about 550,000, but believed by ANIMALS 24-7 and the United Nations Food & Agricultural Organization to be about half that, “and maybe they will get more, maybe not.
“The director of animal husbandry doesn t care if the animals are not being euthanized humanely,” Girardi continued, describing how officials were killing dogs with magnesium sulfate, a method listed as unacceptable by the American Veterinary Medical Association at least since 1993.
“He wants the streets cleaned up. He gets too many complaints from tourists about the bad condition of street dogs, so his answer is to kill them all. End of story,” Girardi said, after trying to introduce Ida Bagus Ketut Alit to current rabies control literature from the World Health Organization, World Society for the Protection of Animals, the Alliance for Rabies Control, and U.S. National Association of Public Health Veterinarians.
“I asked if I could buy vaccines for East Bali and our clinic, and he said no, they are only for use by the government. I asked about prevention for East Bali and he refused to listen,” Girardi continued.
Girardi reported similar results from meeting with Bali Directorate Center for Disease Control chief Wilfred Purpa. “He told us that strays are illegal in Indonesia, but we can t get a definition of ‘stray,'” Girardi recounted. “Ninety percent of Bali’s dogs live on the streets, owned or unowned. His plan is to cull all the stray dogs. He is not concerned with incidental deaths of non-target species, and does not feel there are any human health concerns with distributing baited meat around the beaches and populated areas.”
More than half of the human population of Bali is in the southeastern quadrant of the island, just north of the Denpasar airport, near the BAWA headquarters and also the head office of the Bali Street Dog Foundation.
The rabies control strategy recommended by WHO, WSPA, the Alliance for Rabies Control, and the National Association of Public Health Veterinarians calls for vaccinating the entire dog and cat population if possible, 70% at minimum, to create a vaccinated barrier between infected animals and other animals and people. Enlisting animal welfare societies to help vaccinate is part of the protocol. But BAWA, trying for weeks to volunteer, reported mostly getting the runaround.
Girardi eventually learned from Dewa Dharma, DVM, who helped to legally incorporate BAWA, that “The government purchased rabies vaccines produced in Java which only provide immunity for six months. The government purchased 20,000 canine vaccines about a month ago and is intending to purchase another 30,000. However, two months after the first four rabies deaths, they have only used 2,000 of the 20,000.
“The government has now released some canine rabies vaccines to our vets,” Girardi at last e-mailed on January 5. “However we are only permitted to use these on dogs within the infected area.”
Meanwhile, reported Jakarta Post Denpasar correspondent Luh De Suriyani, “The Denpasar-based Bali Badung Veterinary Main Office has called on local administrations to closely monitor monkey colonies in their respective areas to help contain the rabies outbreak.”
The veterinary authorities expressed concern about monkeys becoming infected at any of the 48 sites on Bali where troupes live, four of which are major tourist attractions.
“In countries such as India and Pakistan, rabies among monkeys has never been reported,” a veterinarian identified only as Soegiarto said. “But that doesn’t mean we can be complacent about it. The main thing is to monitor the monkey colonies and educate people, particularly in tourist spots, about the danger of rabies.”
Responded U.S. Centers for Disease Control & Prevention rabies program director Charles Rupprecht, “Why would one be concerned about monkeys when dogs are not even being vaccinated?”
“There has been great delay in responding according to international recommendations to this outbreak,” fumed globally recognized rabies control expert Henry Wilde, of the Chulalongkorn University faculty of medicine in Bangkok, Thailand. “Thus rabies is surely by now present in other parts of Bali, besides the locations of the first known outbreaks. They will have to vaccinate at least 75% of all dogs and cats on Bali or learn to live with endemic canine rabies.
“This is a mess,” Wilde continued. “It is a repeat of what I experienced at Flores, where Indonesian officials killed more than 500,000 dogs a decade ago, while more than 100 people died of rabies, and the outbreak remains uncontained.
“You have total knuckleheads there in government,” Wilde assessed. “Bali would be an ideal place to make a major effort to vaccinate all dogs on the island, combining this with testing immunological population control technology, which is now known but needs to be tested in the real world. It could be combined with testicular zinc injection for the males,” Wilde suggested. “We have at least one veterinary scientist in Bangkok who could assist in such a project, together with staff from WHO and the U.S. CDC. I must, however, admit that I am sceptical that local officials are interested. It never happened in Flores, and they still have canine rabies.”
Use Thai example
Said the veterinary scientist Wilde mentioned, Chulalongkorn University faculty of medicine colleague Thiravat Hemachudha, “Here in Thailand, although we have reduced human rabies deaths down to fewer than 10 from 300 a year, we still have to give post-exposure prophylaxis to 500,000 persons per year, reflecting how bad it has been as the result of not controlling dog population. We also have spent several hundred millions per year for vaccinating dogs, mostly owned. Please do not follow our bad example,” he pleaded. “Use our example,” which looks very good compared to the Indonesian record, “as a bad example, to develop a new action plan involving the public, quick humane methods of sterilization, and attractive ways to convince public to bring the public dogs in for sterilization and vaccination.”
“If leadership is not coming from the government,” wondered Rupprecht, “Are there no prominent public figures in the country to serve as a rallying point? Outside international pressure causes a bunker mentality,” he warned. “We are all here to help, not to force. This has to begin with an of the people, by the people, for the people philosophy. There is only one earth and one rabies from a global perspective,” Rupprecht explained, “not a center to the infectious disease universe. The solutions to dog rabies elimination are clear. While human prevention is vital, this is not HIV, flu, etcetra this is a zoonosis in which homo is secondary.”
Meanwhile, updated Luh De Suryani of the Jakarta Post, “a four-year-old boy became the probable fifth human victim of the Bali outbreak.”
“The Badung health authority did not inform the press about the boy’s death, Luh De Suryani wrote. “The Jakarta Post learned about it from a source who declined to be named because he was not authorized to speak to journalists. The boy was a resident of Kutuh village, South Kuta, which has been classified as a rabies-prone area. Kutuh village chief I Wayan Litra confirmed that he was bitten by a dog six months ago. The dog who bit him died a week later.”
“Soon after the boy came down with a high fever but was nursed back to health. Then last week he began convulsing uncontrollably, so his parents took him to Sanglah Hospital, where he died,” the chief said.
Noted Luh De Suryani, “Banners and billboards have been put up in the area to warn people against transporting dogs, cats, or primates into and out of Bali. Also, 503 dogs have been culled from South Kuta.”
But the outbreak appeared to be farther than ever from control.